The NIP’s Design and Content

To implement the NIP, the working group had to overcome some organizational and logistical challenges. Resistance to organizational change was one of the challenges.

Resistance emanated as a result of the potential staff vacancies that would be created while the new nurses would be participating in the internship program. Some of the other obstacles dealt with the implementation of the multiple program components. First, scheduling the number of interns in the different nursing units was one challenge that had to be met. Initially, all unit managers wanted the interns to come to their unit even if it was a critical care unit. A second logistical challenge dealt with scheduling the interns to attend the required program classes. Many of the classes were open to the hospital nursing staff. Thus, if the nurse interns filled all the seats available, then the opportunity to attend the class was significantly reduced for other hospital nursing staff members. In summary, planning and implementing the NIP is succinc tly described by one of the co-leaders, “…it was like putting a puzzle together…you had many pieces.”²²⁰

Presently, in addition to managing the logistics of multiple program components, the program has to integrate new nurses into an internship rotation as t hey arrive at NMC SD at different times throughout the year. Different factors affect the arrival of these nurses to the command. Some possible examples include college graduation date,

218 Blanzola, Cheri, Internship Overview, Nurse Internship Program Guide, NMC SD, January 2001.

219 Ibid.

220 Telephone Conversation Between LCDR Blanzola, C., and the Author, 27 January 2003, LCDR Blanzola was one of the leaders of the working group, which planned the implementation of the NIP at NMC SD.

accession contract specifications, assignment by detailers, and time of OIS attendance.

Therefore, due to the different intern arrival dates, the internship rotations are scheduled on an ongoing basis throughout the year. New nurses who arrive at close intervals to each other may constitute an intern rotation group. How ever, as other Ensigns arrive at the command, they join the current internship rotation and participate in a flexible orientation plan until the next internship rotation begins. This is in contrast to the civilian internship examples found in the literature review, in which each class was limited in the number of candidates and the number of internship groups offered in a year. As a result, the NIP at NMC SD is an ongoing dynamic process with nurses rotating in and out as they enter and complete the program.²²¹

New nurses fall under the Director of Nursing Services (DNS) Nursing Administration Directorate while participating in the NIP. This type of staff classification provides an advantage as potential conflicts between training and staff requirements of a unit may be limited or possibly eliminated. In contrast, in the previous orientation program, new nurses went directly to clinical spaces to fill nursing vacancies and were under the direct supervision of the DO. The NIP director and the NIP coordinator²²², provides direction to the nurse interns.

NC officers constitute the greatest portion of the internship with an average of thirteen nurses per rotation, but rotations may have up to thirty nurses depending on seasonal fluctuations.²²³ The program is also open to civilian nurses who are hired to fill nursing positions designated for civilian employment at NMC SD. Qualifications for program participation consist of having graduated from an accredited school of nursing and having less than six months of c linical nursing experience.²²⁴

The new nurses participate in the NIP for a period of sixteen weeks of skill acquisition. Program components include classroom lectures, bi-monthly group

221 Telephone Conversation Between NIP Director at NMC SD, Lindeman, Roslyn, and the Author, 12 February 2003.

222 The NIP Coordinator manages the Clinical Education division under the Staff Education and Training department.

223 E-Mail Correspondence from NIP Director at NMC SD, Lindeman, Roslyn, to the Author 14 January 2003.

224 Blanzola, Cheri, Eligibility, Nurse Internship Program Guide, NMC SD, January 2001.

seminars, clinical experience in a direct patient care setting, group presentations, and patient care conferences.²²⁵ Each of these components has a direct link to skills the new nurse will need to learn and eventually apply in the patient care setting. Classroom time is devoted to at least 20 hours of lecture material consisting of a variety of topics directly linked to patient care. The NIP coordinator oversees the class content presented in the lectures. According to the NIP coordinator at NMC SD “the classes the interns take vary depending on what classes are offered during the time they are in the program.”²²⁶ Appendix D contains the required courses and other classes that may be taken as schedules and time permits. In summary, the classes offer the knowledge necessary to provide patient care.

As a critical and balancin g component of the program, the clinical rotation yields a rich environment where the nurse intern experiences a variety of inpatient care settings.

The interns rotate between medical-surgical floors, pediatric, obstetrics, and a critical care or other specialty area. Table 3.1 displays the rotation areas and the length of time a nurse intern spends in each area. Depending on the number of nurse interns in a rotation, a psychiatric unit rotation may be part of the clinical rotation. At least 100 hours per month are devoted to the clinical experience. An objective of the clinical experience is to integrate the content of the classroom lectures with actual clinical situations. This integrated schedule provides the nurse intern with a direct and concrete application of the material discussed in the classroom to a patient setting. Thus, topics such as physical assessment, pathophysiology, diagnosis, treatment, nursing interventions, and patient evaluation are learned in class and then applied in the clinic al setting.²²⁷ Appendix E provides a sample of the “Unit Clinical Plan” that provides guidance to the intern, preceptor, and DO during the clinical rotation. Weekly goals, patient assignment, and responsibilities are outlined in the plan. The plan is only offers guidelines for the program participants, as the clinical rotation is adapted to meet the individual learning needs of each nurse intern.

225 Lindeman, Roslyn, and Blanzola, C., LCDR, Nurse Internship Program (NIP): The “Pathway” to Clinical Comfort, Confidence, and Competence, Slide Presentat ion, Slide 5.

226 E-Mail Correspondence from NIP Coordinator, LCDR Stensrud, to the Author, 03 February 2003.

227 Lindeman, Roslyn and Blanzola, C., LCDR, Slide Presentation, Slide 6.

Table 3.1. Nursing Areas and Length of Rotation (From: Nurse Internship Program Guide)²²⁸.

Rotating Areas Length of Rotation

Medical Surgical Nursing Four Weeks Medical Surgical Nursing II Four Weeks

Pediatric Nursing Two Weeks

Obstetrical Nursing Two Weeks

Specialty Nursing/Critical Care Nursing One Week

The clinical rotation schedule in the unit consists of 12-hour day shifts and includes weekends. The maximum number of nurse interns per rotation is six per unit.

They are divided into three interns per unit per day since the units operate under 12 -hour rotating shifts.²²⁹ However, as explained by the program director, four interns per group is a more manageable situation at the unit level, since there will be two interns per unit per day. It is the number of interns in the program at any one time that determines the number of intern rotating through the units at any one time.

As classes have teaching objectives, the clinical experiences also have objectives designed to assist the nurse interns in learning and applying clinical skills. Table 3.2 contains the clinical experiences linked to a learning objective or an experience that nurse interns learn or obtain when they rotate through a specific unit. Inherent in the clinical content of the program is the nurse intern’s participation in all facets of patient care.

“This includes patient assessment, prioritization, delivery, and evaluation of nursing care for one or a group of patients.”²³⁰ These skills are essential components of the program.

Del Bueno (1994) warns of the lack of prioritization, and critical thinking skills that new

228 Blanzola, Nurse Internship Program Guide, NMC SD, Rotations, January 200 1.

229 E-Mail Correspondence from NIP Coordinator at NMC SD, Lindeman, Roslyn, to the Author, 14 January 2003.

230 Naval Medical Center San Diego, Nurse Internship Program – Specifics,

[http://www.nmcsd.med.navy.mil/SiteMaker/websitefiles/nmcsdpub/command_info.cfm?id=208], February 2003.

nurses exhibit.²³¹ Benner (1984) also identified, by means of the Dreyfus skill acquisition model, the need for new nurses to learn prioritization skills when faced with a barrage of information. Therefore, priority setting is an essential component of the clinical experience.²³² The contents of the NIP are designed to offer a balanced clinical experience that provides the opportunity for new nurses to acquire the skills necessary to transition confidently to the role of healthcare provider on the unit.

Table 3.2. Clinical Experiences Learning Objectives (After: Nurse Internship Program Guide)²³³.

Clinic Experiences Learning objective

Command Orientation and Clinical Orientation

Safety, confidentiality, infection control, universal precautions

Surgical Experience Intern follows a patient through

preoperative teaching, day of surgery, post-operative report, and care of patient post operatively. Operating room is optional and is scheduled on a case-by-case basis.

Nurse Mentorship Experience Mentorship with an experienced clinical nurse leader to gain a better understanding of the roles and responsibilities of DO Outpatient Clinic Rotation One day rotation in a specific outpatient

clinic allows intern to observe patient care in an outpatient setting and gain an awareness of activities in the clinic.

Special or Critical Care Area Rotation ²³⁴ One or two days spent rotating through the corresponding critical or specialty are while intern is assigned to a rotation (i.e.

Pediatrics linked with a one or two day rotation in the Pediatric Intensive Care Unit Intern Grand Rounds – 20 minute

presentation of a case study on a patient to the intern group at the end of the internship program

Incorporates knowledge and skills learned through the Medical Surgical Nursing Rotations.

231 Del Bueno, pp. 9-11.

232 Benner, pp. 1 -38.

233 Blanzola, Cheri, Rotations, Nurse Internship Program Guide, NMC SD , January 2001.

234 The specialty care areas include the intensive care unit, cardiac care unit, pediatric intens ive care unit, Neonatal Intensive care unit, Emergency Department, Post anesthesia Care Unit, Mental Health, Operating Room, Outpatient clinics, 5 West, 5 North, 5 East, 4 West, 4 North – Same Day Surgery, 3 East, 3 West, Labor and Delivery, 2 East. Comman d Information, NIP – Specialty Care Area Choices, On Line:

During each of the clinical rotations, the constant interactions between the program director, key unit nursing personnel, and the nurse interns are the catalyst in the nurse interns’ skill acquisition. These interactions between the program partic ipants promote a learning environment. One key role is that of the program coordinator. This person has a proactive role in the program, matching up teaching opportunities in the hospital with the learning needs of each nurse intern. A second key role is that of the Clinical Nurse Specialist (CNS) or clinical educator (CE)²³⁵ as they are able to provide education and knowledge about patients in the clinical setting. The division officer (DO) may substitute for the CNS when they are not available as they also have experience in providing nursing care to the unit’s patient population. Finally, the third key player is the clinical preceptor who, along with the CNS or DO, offers direct guidance to the nurse intern while providing direct patient care. Finally , it is a combined effort between all key members, including the nurse interns that ensures the clinical experiences are integrated with each nurse intern’s learning goals and objectives.